[Prevention of bleeding during tubeless percutaneous nephrolithotomy].

INTRODUCTION: Nephrostomy tube placed after percutaneous removal of kidney stones can cause pain and discomfort in the early postoperative period [1, 2]. A tubeless percutaneous nephrolithotomy (PCNL) is considered as alternative approach. However, the most serious complication after tubeless procedure is a development of active uncontrolled bleeding from percutaneous tract in the early postoperative period. AIM: To improve the results of surgical treatment of kidney stones by evaluation of efficiency of using hemostatic matrix during tubeless PCNL. MATERIALS AND METHODS: A total of 113 patients with large kidney stones undergone to the tubeless PCNL for the past 9 years in our clinic. The external or internal stent was put for the drainage of upper urinary tract for 2 and 14 days, respectively. All patients were divided into 2 groups, depending on severity of bleeding (group 1 - no bleeding vs. group 2 - mild bleeding). Each group was further divided into two subgroups based on the technique and type of drainage of upper urinary tract at the end of the surgery. In the main group (n=74) the hemostatic matrix based on lyophilized thrombin 2000 IU was injected in percutaneous tract at the end of the surgery. The control group included 39 patients who underwent mini-PCNL without using hemostatic matrix. The blood loss, intensity of urine leakage from percutaneous tract (duration, visual analog scale) and degree of fluid extravasation in pararenal fat estimated by US were evaluated. RESULTS: The mean operative time was 47.5+/-3.6 min (52, 58, 38 and 49 min in subgroup I, II, III and control group, respectively). Hemoglobin drop was 9.3+/-4.1, 12.1+/-7.5, 14.6+/-11.2 and 10.6+/-5.9 in subgroups I, II, III and in the control group, respectively, while duration of hematuria was 16.1, 20.3, 28.5 and 22.9 hours, respectively. Fluid extravasation in pararenal space was found in 1 out 7 patients in subgroup III and control group, respectively (p<0.05). The dilatation of collection system (after double-J) persisted in 18.1%, 20% 22.2% and 13.3% cases in subgroup I, II, III and control group, respectively. There were no significant differences in other evaluated parameters. In 1 case in the control group there was severe bleeding which required selective embolization of the renal artery. CONCLUSION: The use of hemostatic matrix is an additional important measure which allows to prevent active bleeding from the percutaneous tract in early postoperative period. Moreover, the hemostatic matrix contributes to the sealing of tract and reduces the risk of fluid extravasation in pararenal space after mini-PCNL.

[Multi-tract percutaneous nephrolithotomy in the management of staghorn stones].

AIM: To compare the results of a single tract versus multi-tract percutaneous nephrolithotomy (PNL) MATERIALS AND METHODS: Over a period of 6 years, a total of 2,264 PNLs was performed at the N.A. Lopatkin Scientific Research Institute of Urology and Interventional Radiology, of which 875 PNLs were done for stage K3-K4 staghorn calculi. Among them, 244 (27.7%) patients underwent multi-tract PNL. We included 873 patients in our study. The median stone size was 59 (46; 88) mm. Two, three and four percutaneous tracts were used in 165 (67.6%), 63 (25.8%) and 14 (5.7%) patients, respectively. In 126 of 244 (52%) patients, a set for mini-percutaneous surgery with 14.5 and 15.5 Ch tubes was used as additional access. RESULTS: The effectiveness of single and multi-track PNL was 53.6%, and 83.8%, respectively. The mean operating time for PNL using one, two, three and four percutaneous tracts was 77.2+/-29.9, 85.7+/-26.9, 116.6+/-28, and 144.0+/-12.2 min, respectively. The median length of hospital stay for single and multi-track PNL was 6.6 (5.4, 8.7) vs. 10.2 (8.6, 12.3) days. Intra- and early postoperative infectious complications occurred in 101 (16.1%) and 54 (22.4%) patients, who underwent single and multi-track PNL, respectively. Bleeding occurred in 88 (13.9%) and 50 (20.8%) patients, respectively. After single and multi-track PNL, 54 (8.6%) and 21 (8.8%) patients needed a blood transfusion, respectively. CONCLUSION: Multi-track PNL is highly effective as a treatment modality for patients with complex forms of nephrolithiasis. Using the mini-tool significantly reduces the risk of bleeding when performing the additional access.

[Analysis of clinical effectiveness and risk factors for complication of percutaneous nephrolototripsia in patients with a solitary kidney].

RELEVANCE: Management of patients with large and staghorn stones of a solitary kidney is widely debated among urologists and has not been sufficiently investigated, which determined the relevance of this study. MATERIALS AND METHODS: The study comprised 80 patients with large (>20 mm) and staghorn stones of an anatomically or functionally solitary kidney. Of them, 58 patients underwent percutaneous nephrolithotripsy (PNL), and 22 had open surgery. The criterion of the treatment effectiveness was the complete stone clearance or small residual fragments sized less than 3 mm. The safety criterion was the absence of intra- and postoperative complications, according to Clavien-Dindo grading system. The study analyzed the following factors influencing the effectiveness and safety of PNL: the number of accesses; nephroscope diameter; use of a nephroscope sheath; type of lithotripter; size, density, type and composition of the stone. RESULTS: Percutaneous nephrolithotripsy demonstrated statistically significantly better safety results compared with open surgery with comparable effectiveness. Long-term stone recurrence rate after PNL and open surgery was 10.4 and 18.2%, respectively. PNL resulted in a statistically significant improvement in the kidney function while it worsened after open surgery. The effectiveness of PNL depends on the stone type and size and the kind of lithotripter. It was 7.5 times greater for a large stone than for staghorn calculi and 4.6 times higher for stones sized less or equal 45 mm than for those sized > 45 mm. Ultrasonic lithotripter was 2.2 times more effective than another type of lithotripter. The safety of PNL depends on the nephroscope diameter, of a sheath, the number of accesses, the type of lithotripter and the type of stone. Using a 24-Ch nephroscope was 3.6 times safer than that with a diameter greater than 24-Ch; not using a sheath was 3.2 times safer than using it; one access was 3 times safer than at multiple ones; using an ultrasound lithotripter was 2.7 times safer than with another type of lithotripter; treating a large stone was 2.1 times safer than a staghorn stone. CONCLUSION: The study findings can be used to optimize the treatment of patients with large and staghorn stones of a solitary kidney.